<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005361
Report Date: 02/01/2024
Date Signed: 02/01/2024 11:21:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231201144701
FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:ELISA WEATHERSFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: 85DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elisa WeathersTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not ensure facility has sufficient staffing to meet the care needs of residents
Staff do not ensure residents receive bathing service in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Elisa Weathers and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Weathers and 15 staff members (S1-S15). S1, S6, S7, S8, S10, S11, S12, and S13 work in memory care. S3, S4, S5, and S11 work in assisted living. LPA Moleski interviewed seven residents (R1-R7). R1, R2, R3, R5, R6, and R7 live in assisted living. R4 lives in memory care.

In an interview, Weathers said staff hours had been reduced recently. LPA Moleski reviewed staff schedules and resident rosters for this facility.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231201144701

FACILITY NAME:SUMMERSET ASSISTED LIVINGFACILITY NUMBER:
347005361
ADMINISTRATOR:ELISA WEATHERSFACILITY TYPE:
740
ADDRESS:2341 VEHICLE DRTELEPHONE:
(916) 330-1300
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:135CENSUS: 85DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elisa WeathersTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure memory care residents are checked on every 2 hours
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Elisa Weathers and explained the purpose of the visit.

This investigation consisted of interviews. This facility does not document when or if two-hour checks are performed in the memory care unit.

LPA Moleski interviewed nine staff members (S1, S6, S7, S8, S10, S11, S12, S13, and S15) Of these, S6, S10, and S15 said staff members are not able to perform two-hour checks on memory care residents. S1, S7, S8, S11, S12, and S13 said staff are able to perform two-hour checks on memory care residents.

The department has determined the following as it relates to the allegation that staff do not ensure memory care residents are checked on every 2 hours: [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20231201144701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
VISIT DATE: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Weathers.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20231201144701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
VISIT DATE: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In memory care during December 1-15, there were two caregivers and one med tech scheduled most days for the morning and evening shifts, and two caregivers scheduled for most night shifts. There were 32 residents in memory care as of 12/11/23. In assisted living during the month of December, there were three caregivers and one med tech scheduled most days for morning shifts, two caregivers and one med tech scheduled most days for evening shifts, and two caregivers scheduled for most night shifts. There were 52 residents in assisted living as of 12/11/23.

In interviews, S1, S3, S4, S5, S6, S7, S8, S10, S11, S12, S13, and S15 said there were not enough staff at the facility to sufficiently meet residents’ needs. These same staff members said that residents were not being showered adequately due to the insufficient staffing. S1 said staff cannot always complete scheduled showers, and said they could “guarantee” that there weren’t enough showers being done. S3 said residents have to wait for staff to become available to receive assistance, and said that scheduled showers are skipped when they get too busy. “There’s showers that ain’t getting done,” S4 said. S5 said scheduled showers are sometimes skipped when staff are busy. “Sometimes we’re not able to give them a shower when they need to,” S6 said. “We don’t have time to do a lot of the care that we’re supposed to,” S7 said. S7 said that sometimes showers are put off until the next day, or whenever staff are able to complete them. S7 also said that staff have to chase after residents who attempt to leave the memory care unit. “It’s hard to get a shower in,” S8 said. S10 said staff will skip showers if busy and try to complete them the next day. S11 said residents have to wait for staff to provide assistance to them, and also that scheduled showers cannot always be done. S11 said that staff “hope for the best” that the next shift will be able to take care of the missed showers. “It’s hard to get showers in while being behind,” S12 said. S12 said the insufficient staffing levels were “unfair” to the residents. S12 said staff cannot get to all of the scheduled showers about three days out of the week. “We’ve fallen behind on all the showers,” S12 said. S13 said that staff try to give residents their scheduled showers, but they often have to delay them when other residents need more immediate attention.

In interviews, R3, R4, R5, R6, and R7 said the facility was not sufficiently staffed. R3, R5, and R7 said they had not received showers as needed, and had not received showers when scheduled. R3 said staff are difficult to get assistance from, and residents have to wait for assistance. R4 said it was “impossible” to get assistance from staff. R5 said residents wait significant time periods for assistance, and said scheduled showers have been skipped for several days in a row before finally receiving a shower. R6 said there aren’t enough caregivers, and residents are waiting longer for assistance. R7 said the facility was understaffed, and that scheduled showers have been skipped multiple times as a result. [continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20231201144701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
VISIT DATE: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Moleski reviewed shower day skin inspection sheets for residents of this facility. These sheets indicate when showers or bed baths were performed by hospice staff or other outside agencies, and when residents refuse showers. LPA Moleski found that residents in both assisted living and memory care did not receive sufficient showers or bed baths during the period of November 1 through December 11, 2023, including, but not limited to, the findings as described below. R5 and R7 live in assisted living. R8-R13 live in memory care. No further shower sheets were available to account for additional showers or bed baths of these residents:

During the time period surveyed, R8 received a shower on 11/29/23, according to the shower sheets. R9 received a shower on 11/8/23, according to the shower sheets. R10 received a shower from hospice staff on 11/8/23, according to the shower sheets. R11 received a shower on 11/28/23, according to the shower sheets. R12 received showers on 11/27/23, 12/3/23, and 12/4/23, according to the shower sheets. R13 received showers on 11/8/23, 11/11/23, and 11/15/23, according to the shower sheets. R5 received showers on 11/2/23, 11/12/23, 11/19/23, 11/21/23, 11/23/23, 11/28/23, 12/5/23, according to the shower sheets.

LPA Moleski reviewed 30 days’ worth of shower sheets for R7. R7 moved into the facility on 12/11/23, according to R7’s admission agreement. R7 received showers on 12/21, 12/27, 1/5, 1/8, and 1/21, according to the shower sheets. R7 refused a shower on 12/31/23, according to a shower sheet.

LPA Moleski reviewed the most recent assessments for R5, R7, and R8-R13. R8 and R11 are to receive standby assistance with two showers per week. R9, R12, R5, and R7 are to receive total assistance with two showers per week. R13 is to receive assistance preparing items for showers two times per week. R10’s assessment indicates that she receives showers from an outside agency.

LPA Moleski reviewed a shower schedule for memory care dated 11/12/23. R8 is scheduled to receive showers every Monday, Wednesday, and Friday. R11 is scheduled to receive sponge baths every Tuesday and Thursday. R12 is scheduled to receive showers on Mondays, Wednesdays, and Saturdays. R13 is scheduled to receive showers every Monday, Wednesday, and Saturday. LPA Moleski reviewed a shower schedule for assisted living dated 1/15/24. R5 is scheduled to receive showers on Tuesdays, Thursdays, and Sundays. LPA Moleski observed a printed schedule posted to the wall in R7’s room. R7 is scheduled to receive showers on Wednesdays and Sundays. [continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20231201144701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
VISIT DATE: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During a previous visit on 12/5/23 regarding an unrelated complaint investigation, LPA Moleski toured the memory care unit on the second floor of the facility. LPA Moleski observed several unsupervised residents in common areas and hallways. LPA Moleski observed that the staff on the second floor were preoccupied with tasks inside resident rooms, while the majority of residents were in a common living room, unattended.

During a previous visit to this facility on 12/26/23, LPA Moleski observed S15 leading R14 back into the facility from an exterior exit door. S15 said that R14 lives in memory care and had wandered outside the facility alone. R14 was not able to answer questions regarding where he had been. S15 said R14 “escapes” frequently, and other residents do as well. S15 said such incidents occur at least once a week. S14 was a witness to the incident, and said that after hearing an alarm go off, S14 looked outside and found R14 walking around. LPA Moleski reviewed R14’s LIC 602. R14 has dementia and is unable to leave the facility unassisted, according to the LIC 602.

The department has determined the following as it relates to the allegations that the licensee does not ensure the facility has sufficient staffing to meet the care needs of residents, and that staff do not ensure residents receive bathing service in a timely manner:

Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Sections 87411(a) and 87464(f)(4). An exit interview was held with Weathers. Appeal rights and a copy of this report were left with Weathers.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20231201144701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/02/2024
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
"(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services."

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to develop a written plan addressing staffing needs at this facility, which shall rectify the insufficient staffing levels as described in this report. Licensee shall send a copy of this plan to LPA Moleski by the POC due date.
vincent.moleski@dss.ca.gov
8
9
10
11
12
13
14
Based on interviews, observations, and record review, staffing was not sufficient to meet the needs of residents, which poses an immediate health, safety and/or personal rights risk.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20231201144701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUMMERSET ASSISTED LIVING
FACILITY NUMBER: 347005361
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/02/2024
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
"(f) Basic services shall at a minimum include: ... Personal assistance and care as needed by the resident ... with those activities of daily living such as ... bathing ..."

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to develop a written plan addressing bathing needs. Licensee agrees to send LPA Moleski a copy of this plan by POC due date.
vincent.moleski@dss.ca.gov
8
9
10
11
12
13
14
Based on interviews and record review, bathing services were not provided as needed and/or as indicated on resident assessments, which poses an immediate health, safety, and/or personal rights risk.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8